Systems and methods for transitioning patient care from signal based monitoring to risk based monitoring

ABSTRACT

A risk-based patient monitoring system for critical care patients combines data from multiple sources to assess the current and the future risks to the patient, thereby enabling providers to review a current patient risk profile and to continuously track a clinical trajectory. A physiology observer module in the system utilizes multiple measurements to estimate Probability Density Functions (PDF) of a number of Internal State Variables (ISVs) that describe a components of the physiology relevant to the patient treatment and condition. A clinical trajectory interpreter module in the system utilizes the estimated PDFs of ISVs to identify under which probable patient states the patient can be currently categorized and assign a probability value that the patient will be in each of the identified states. The combination of patient states and their probabilities is defined as the clinical risk to the patient.

PRIORITY CLAIM

This application is a continuation of U.S. non-provisional patentapplication Ser. No. 16/113,486 filed Aug. 27, 2018 and entitled“Systems and Methods for Transitioning Patient Care from Signal-BasedMonitoring to Risk-Based Monitoring,” which is a continuation of U.S.non-provisional patent application Ser. No. 14/727,696, filed Jun. 1,2015 and entitled “Systems and Methods for Transitioning Patient Carefrom Signal-Based Monitoring to Risk-Based Monitoring,” issued Aug. 28,2018 as U.S. Pat. No. 10,062,456, Attorney Docket No. 3816-11701, whichis a continuation of U.S. non-provisional patent application Ser. No.13/826,441, filed Mar. 14, 2013 and entitled “Systems and Methods forTransitioning Patient Care from Signal-Based Monitoring to Risk-BasedMonitoring, Attorney Docket No. 3816-10601, which is aContinuation-In-Part of the following non-provisional patentapplications:

U.S. patent application Ser. No. 13/689,029, filed on Nov. 29, 2012,entitled “Systems and Methods for Optimizing Medical Care Through DataMonitoring and Feedback Treatment,” Attorney Docket No. 3816-10501; and

U.S. application Ser. No. 13/328,411, filed on Dec. 16, 2011, entitled“Method and Apparatus for Visualizing the Response of a Complex Systemto Changes in a Plurality of Inputs,” Attorney Docket No. 3816-10701;

and also claims priority to the following provisional patentapplications:

U.S. Provisional Application No. 61/727,820, filed on Nov. 19, 2012,entitled “User Interface Design for RAHM,’ Attorney Docket No.3816-10401;

U.S. Provisional Application No. 61/699,492, filed on Sep. 11, 2012,entitled “Systems and Methods for evaluating Clinical Trajectories andTreatment Strategies for Outpatient Care,” Attorney Docket No.3816-10301;

U.S. Provisional Application No. 61/684,241, filed on Aug. 17, 2012,entitled “System and Methods for Providing Risk Assessment in AssistingClinicians with Efficient and Effective Blood Management,” AttorneyDocket No. 3816-10101;

U.S. Provisional Application No. 61/620,144, filed on Apr. 4, 2012,entitled “Systems and Methods for Providing Mobile Advanced CardiacSupport,” Attorney Docket No. 3816-11201;

U.S. Provisional Application No. 61/614,861, filed on Mar. 23, 2012entitled “Systems and Methods for Reducing Morbidity and Mortality whileReducing Length of Stat in a Hospital Setting,” Attorney Docket No.3816-11101;

U.S. Provisional Application No. 61/614,846, filed Mar. 23, 2012,entitled “Systems and Methods for Providing Mobile Advanced CardiacSupport,” Attorney Docket No. 3816/11001;

and

U.S. Provisional Application No. 61/774,274, filed on Mar. 7, 2013,entitled “Systems and Methods for Transitioning Patient Care fromSignal-Based to Risk-Based Monitoring,” Attorney Docket No. 3816-10201,

the entire subject matter of each of the foregoing applications beingincorporated herein by this reference for all purposes.

STATEMENT REGARDING FEDERALLY SPONSORED RESEARCH OR DEVELOPMENT

This invention was made with government support under R43HL117340awarded by the National Heart, Lung, And Blood Institute of the NationalInstitutes of Health. The government has certain rights in theinvention.

BACKGROUND ART

The present disclosure relates to systems and methods for risk-basedpatient monitoring. More particularly, the present disclosure relates tosystems and methods for assessing the current and future risks of apatient by combining data of the patient from various different sources.

Practicing medicine is becoming increasingly more complicated due to theintroduction of new sensors and treatments. As a result, clinicians areconfronted with an avalanche of patient data, which needs to beevaluated and well understood in order to prescribe the optimaltreatment from the multitude of available options, while reducingpatient risks. One environment where this avalanche of information hasbecome increasingly problematic is the Intensive Care Unit (ICU). There,the experience of the attending physician and the physician's ability toassimilate the available physiologic information have a strong impact onthe clinical outcome. It has been determined that hospitals which do notmaintain trained intensivists around the clock experience a 14.4%mortality rate as opposed to a 6.0% rate for fully staffed centers. Itis estimated that raising the level of care to that of average trainedphysicians across all ICUs can save 160,000 lives and $4.3 Bn annually.As of 2012, there is a shortage of intensivists, and projectionsestimate the shortage will only worsen, reaching a level of 35% by 2020.

The value of experience in critical care can be explained by the factthat clinical data in the ICU is delivered at a rate far greater thaneven the most talented physician can absorb, and studies have shown thaterrors are six times more likely under conditions of informationoverload and eleven time more likely with an acute time shortage.Moreover, treatment decisions in the ICU heavily rely on clinical signsthat are not directly measurable, but are inferred from otherphysiologic information. Thus clinician expertise and background play amore significant role in the minute to minute decision making process.Not surprisingly, this leads to a large variance in hidden parameterestimation. As an example, although numerous proxies for cardiac outputare continuously monitored in critical care, studies have demonstratedpoor correlation between subjective assessment by clinicians, andobjective measurement by thermodilution. Experienced intensivistsincorporate this inherent uncertainty in their decision process byeffectively conducting risk management, i.e. prescribing the treatmentnot only based on the most probable patient state, but also weighing inthe risks of the patient being in other more adverse states. From thisperspective, experienced intensivists confront the data overload inintensive care by converting the numerous heterogeneous signals frompatient observations into a risk assessment.

Therefore, there is a clear need for a decision support system in theICU that achieves a paradigm shift from signal-based patient monitoringto risk based patient monitoring, and consequently helps physiciansovercome the barrage of data in the ICU.

BRIEF SUMMARY

Disclosed herein is a risk-based patient monitoring system for criticalcare patients that combines data from any of bedside monitors,electronic medical records, and other patient specific information, toassess the current and the future risks to the patient. The system maybe also embodied as a decision support system that prompts the user withspecific actions according to a standardized medical plan, when patientspecific risks pass a predefined threshold. Yet another embodiment ofthe described technologies is an outpatient monitoring system whichcombines patient and family evaluation, together with information aboutmedication regiments and physician evaluations to produce a risk profileof the patient, continuously track its clinical trajectory, and providedecision support to clinicians regarding when to schedule a visit oradditional tests.

According to one implementation, a risk based monitoring applicationexecuting on a system processor comprises a data reception module, aphysiology observer module, a clinical trajectory interpreter module,and a visualization and user interaction module. In an exemplaryembodiment, the data reception module may be configured to receive datafrom bedside monitors, electronic medical records, treatment device, andany other information that may be deemed relevant to make informedassessment regarding the patient's clinical risks, and any combinationthereof of the preceding elements.

The physiology observer module utilizes multiple measurements toestimate Probability Density Functions (PDF) of Internal State Variables(ISVs) that describe the components of the physiology relevant to thepatient treatment and condition. The clinical trajectory interpretermodule may be configured with multiple possible patient states, anddetermine which of those patient states are probable and with whatprobability, given the estimated probability density functions of theinternal state variables.

In various embodiments, the clinical trajectory interpreter moduledetermines the patient conditions under which a patient may becategorized and is capable of also determining the probable patientstates under which the patient can be currently categorized, given theestimated probability density functions of the internal state variables.In this way, each of the possible patient states is assigned aprobability value from 0 to 1. The combination of patient states andtheir probabilities is defined as the clinical risk to the patient.

The visualization and user interactions module takes i) time series ofphysiologic measurements acquired continuously or intermittently andpatient specific identifiers such as condition, demographics, visualexaminations from the data reception module; ii) time series ofprobability density functions of internal state variables estimated fromthe physiology observer module; and time series of the probabilitiesthat the patient is at particular state and the hazard level of therespective risks from the clinical trajectory interpreter module. Thenit visualizes this data on graphs which represent the dependence of thevariables with time, by either directly plotting them on a screen, or inthe case of probability density functions plotting them by encoding thelikelihood at particular point of time and at particular value with acolor scheme. The visualization and user interactions module may alsovisualize the current risks to the patient by representing them withboxes of different size and color, the size of the box corresponding tothe probability of a patient state at particular point in time and thecolor of the box corresponding to its hazard level. Additionally, thevisualization and user interactions module can allow the users to setalarms based on the patient state probabilities, share those alarms withother users, take notes related to the patient risks and share thosenotes with other users, and browse other elements of the patient medicalhistory.

According to one aspect of the disclosure, a computer-implemented mediumand method for risk based monitoring of patients comprises: A)acquiring, with a computer, data associated with a plurality of theinternal state variables each describing a parameter physiologicallyrelevant to one of a treatment and a condition of a patient; B) storing,in a computer accessible memory, the acquired data associated with theplurality of the internal state variables; C) generating, with acomputer, estimated probability density functions for the plurality ofthe internal state variables; and D) identifying, with a computer, fromthe generated probability density functions of the internal statevariables, into which of a plurality of possible patient states thepatient is currently categorizable and generating a probability valueassociated with each identified possible patient state. In oneembodiment, the probability value associated with the identifiedpossible patient states is between 0 and 1. In another embodiment, themethod further comprises: E) presenting on a screen the probabilityvalues and their associated respective identified possible patientstates, wherein the combination of identified possible patient statesand their associated respective probability values is defined as theclinical risk to the patient.

According to another aspect of the disclosure, a risk based monitoringsystem for monitoring patients comprises: a processor; a memory coupledto the processor; a data reception module, operably coupled to aplurality of sources of information relative to a patient, for acquiringdata associated with a plurality of the internal state variables eachdescribing a parameter physiologically relevant to one of a treatmentand a condition of a patient; a physiology observer module, incommunication with the data reception module, and configured to generateprobability density functions of the internal state variables; aclinical trajectory interpreter module, in communication with thephysiology observer module, and configured to identify into which of aplurality of possible patient states the patient is currentlycategorizable and to generate a probability value associated with eachidentified possible patient state. In one embodiment, the method furthercomprises: a user interaction module, in communication with the clinicaltrajectory interpreter and the data reception module and memory, forpresenting the probability values and their associated respectiveidentified possible patient states, wherein the combination ofidentified possible patient states and the associated respectiveprobability values is defined as the clinical risk to the patient.

According to still other aspects of the disclosure, certainmeasurements, such as Hemoglobin, are available to the system with anunknown amount of time latency, meaning the measurements are valid inthe past relative to the current time and the time they arrive over thedata communication links. The physiology observer module may handle suchout of sequence measurements using back propagation, in which thecurrent estimates of the ISVs are projected back in time to the time ofvalidity of the measurements, so that the information from the latentmeasurement can be incorporated correctly. Accordingly, in accordancewith another aspect of the disclosure, a computer-implemented method forrisk based monitoring of patients, comprises: A) acquiring, with acomputer, data associated with a plurality of the internal statevariables each describing a parameter physiologically relevant to one ofa treatment and a condition of a patient, not all of the data associatedwith the plurality of the internal state variables with at the sameperiodicity; B) storing, in a computer accessible memory, the acquireddata associated with the plurality of the internal state variables; C)generating, with a computer, estimated probability density functions forthe plurality of the internal state variables; and D) identifying, witha computer, from the generated probability density functions of theinternal state variables, into which of a first plurality of possiblepatient states P(S₁), P(S₂), P(S₃), . . . P(S_(n)), the patient couldhas previously been categorizable and generating a probability valueassociated with each identified possible prior patient state. In oneembodiment, generating estimated probability density functionscomprises: C1) generating estimated probability density functions forthe first plurality of the internal state variables at a current timestep t_(k); and C2) generating probability density functions for theplurality of the internal state variables at a another time stept_(k−N), where N is an integer value greater than 1, by evolvingbackwards from the probability estimates at time step t_(k) to the timestep t_(k−N) using a defined transition probability kernel.

BRIEF DESCRIPTION OF THE DRAWINGS

It should be understood at the outset that although illustrativeimplementations of one or more embodiments of the present disclosure areprovided below, the disclosed systems and/or methods may be implementedusing any number of techniques, whether currently known or in existence.The disclosure should in no way be limited to the illustrativeimplementations, drawings, and techniques illustrated below, includingthe exemplary designs and implementations illustrated and describedherein, but may be modified within the scope of the appended claimsalong with their full scope of equivalents.

In the drawings;

FIG. 1 illustrates conceptually a medical care risk based monitoringenvironment in accordance with the disclosure;

FIG. 2A illustrates conceptually a basic schematic of the physiologyobserver module in accordance with the disclosure;

FIG. 2B, FIG. 2C and FIG. 2D illustrate conceptually exemplary graphs ofprobability density functions for select ISVs as generated by thephysiology observer module in accordance with the disclosure;

FIG. 3 illustrates conceptually a non-limiting example of a physiologyobserver process in accordance with the disclosure;

FIG. 4 illustrates conceptually a non-limiting example of the physiologyobserver process in accordance with the disclosure;

FIG. 5 illustrates conceptually a time line, wherein back propagation isused to incorporate information in accordance with the disclosure;

FIG. 6 illustrates conceptually an example of a process involving meanarterial blood pressure (ABPm) in accordance with the disclosure;

FIG. 7 illustrates conceptually an example of resampling in accordancewith the disclosure;

FIG. 8 illustrates conceptually a clinical trajectory interpreter moduleusing joined Probability Density Functions of ISVs and performing stateprobability estimation to calculate the probabilities of differentpatient states in accordance with the disclosure;

FIG. 9 illustrates conceptually a non-limiting example of a definitionof a patient state employed by the clinical trajectory interpretermodule in accordance with the disclosure;

FIG. 10 illustrates conceptually a non-limiting example of how aclinical trajectory interpreter module may employ the definition ofpatient states to assign probabilities that the patient may beclassified under each of the four possible patient states at aparticular point of time;

FIG. 11 illustrates conceptually an alternative approach of estimatingthe probabilities for different patient states in accordance with thedisclosure;

FIG. 12 illustrates conceptually a non-limiting example of a definitionof patient states assigned with hazard levels by the clinical trajectoryinterpreter module in accordance with the disclosure;

FIG. 13 illustrates conceptually patient states and their respectiveprobabilities organized into tree graphs called etiologies in accordancewith the disclosure;

FIG. 14 illustrates conceptually an exemplary etiology tree for a givenset of patient states and physiologic variables in accordance with thedisclosure;

FIG. 15 illustrates conceptually a method for calculating the utility ofdifferent measurements in accordance with the disclosure;

FIG. 16 illustrates conceptually one possible realization of integrationof external computation generated from third party algorithms inaccordance with the disclosure;

FIG. 17 illustrates conceptually an example of integration instructionsof an external computation in accordance with the disclosure;

FIG. 18 illustrates conceptually an additional example of integrationinstructions of an external computation in accordance with thedisclosure;

FIG. 19 illustrates conceptually example functionalities of thevisualization and user interactions module in accordance with thedisclosure;

FIG. 20 illustrates conceptually an example of a summary view that mayconvey on a single screen a risk profile for each patient in aparticular hospital unit in accordance with the disclosure;

FIG. 21 illustrates conceptually one possible realization of a viewdescribing the ongoing risks of the patient in accordance with thedisclosure;

FIG. 22 illustrates conceptually how the slider on top of the patientview may be utilized in reviewing the history of the patient risks inaccordance with the disclosure;

FIG. 23 illustrates how the user can navigate the etiology tree byclicking on the composite patient state and viewing the constituentpatient states in accordance with the disclosure;

FIG. 24 illustrates conceptually how in the same framework the user mayview the predicted risks for the patient by sliding the slider ahead ofcurrent time in accordance with the disclosure;

FIG. 25 illustrates conceptually how the user may choose to set an alarmfor a particular risk in accordance with the disclosure;

FIG. 26 illustrates conceptually yet another possible visualization ofthe patient risk trajectory, i.e., the evolution of the patient states'probabilities associated with particular risks in accordance with thedisclosure;

FIG. 27 illustrates conceptually how the system may directly visualizethe probability density functions of various internal state variables inaccordance with the disclosure;

FIG. 28 illustrates conceptually an example of a tagging feature that auser interface may implement in accordance with the disclosure;

FIG. 29 illustrates conceptually a Newsfeed view of the user interfacein accordance with the disclosure;

FIG. 30 illustrates conceptually a Condition Summary View of the userinterface in accordance with the disclosure;

FIG. 31 illustrates conceptually the ability for the user interface toinclude and display reference material, which may be accessed throughthe Internet; or stored within the system in accordance with thedisclosure;

FIG. 32 illustrates conceptually a general Dynamic Bayesian Network(DBN) that may be employed to capture the physiology model of the HLHSstage 1 palliation patients in accordance with the disclosure;

FIG. 33 illustrates conceptually several equations that may be used tomodel the dynamics of the HLHS stage 1 physiology in accordance with thedisclosure;

FIG. 34 illustrates conceptually example equations that may be used toabstract the relationships between the dynamic variables in the modeland the derived variables in accordance with the disclosure;

FIG. 35 illustrates conceptually a possible observation model that maybe used to relate the derived variables with the available sensor datain accordance with the disclosure;

FIG. 36 illustrates conceptually possible attributes, patient states,and etiology tree that may be used by the clinical trajectoryinterpreter module in the case of the HLHS Stage 1 population inaccordance with the disclosure;

FIG. 37 illustrates conceptually one possible environment in which therisk based monitoring system can be applied to assist clinicians indeciding whether to apply a particular treatment in accordance with thedisclosure;

FIG. 38 illustrates conceptually a non-limiting example set of patientstates relevant to blood transfusion that may be used to inform theblood transfusion decision in accordance with the disclosure;

FIG. 39 illustrates conceptually another application of the risk-basedmonitoring system, applying standardized medical plans in accordancewith the disclosure;

FIG. 40 illustrates conceptually an example application of the riskbased monitoring system combined with a specific type of standardizedclinical plan in accordance with the disclosure;

FIG. 41 illustrates conceptually an example risk stratification that maybe employed by the system in the context of Nitric Oxide treatment inaccordance with the disclosure;

FIG. 42 illustrates conceptually possible patient states that maydescribe the clinical trajectory of an ADHD patient in accordance withthe disclosure;

FIG. 43 lists the available patient evaluation modalities as M1, M2, andM3;

FIG. 44 illustrates conceptually a dynamic model of the patientevolution from state to state abstracted by a Dynamic Bayesian Networkin accordance with the disclosure;

FIG. 45 illustrates conceptually an alternative embodiment for twopredictions of how the patient state can transition in a single monthgiven medication change or a dosage change in accordance with thedisclosure;

FIG. 46 illustrates conceptually one possible embodiment and scenario ofvisualization displaying the patient clinical trajectory and risks inaccordance with the disclosure;

FIG. 47 illustrates conceptually an evaluation of the patient and thepatient trajectory at week 9 at which point risk based patientmonitoring system determines a probability distribution function for thestate of the patient for each of the past nine weeks in accordance withthe disclosure;

FIG. 48 shows a follow-up evaluation based on teacher and parentVanderbilt diagnosis in accordance with the disclosure;

FIG. 49 shows consequent evaluation based on all availablemeasurements—office visit, parent and teacher evaluation, whichestablishes high probability for significant improvement in accordancewith the disclosure;

FIG. 50 shows yet another follow-up at which point it is establishedthat the patient is most probably stably improved, and has been stablyimproved between the two evaluations in accordance with the disclosure;

FIG. 51 shows a follow-up evaluation of the patient and the patienttrajectory in the absence of measurements, wherein due to the lack ofrecent observation, the uncertainty is increasing in accordance with thedisclosure;

FIG. 52 shows the state of this uncertainty given a full patientevaluation (all measurement modalities) in accordance with thedisclosure; and

FIG. 53 illustrates yet another possible visualization from thedescribed system output. It shows possible patient state transitionsunder changes of treatment plan, e.g., change of medication inaccordance with the disclosure.

DETAILED DESCRIPTION OF SPECIFIC EMBODIMENTS

Technologies are provided herein for providing risk-based patientmonitoring of individual patients to clinical personnel. Thetechnologies described herein can be embodied as a monitoring system forcritical care, which combines data from various bedside monitors,electronic medical records, and other patient specific information toassess the current and the future risks to the patient. The technologiescan be also embodied as a decision support system that prompts the userwith specific actions according to a standardized medical plan, whenpatient specific risks pass a predefined threshold. Yet anotherembodiment of the described technologies is an outpatient monitoringsystem which combines patient and family evaluation, together withinformation about medication regiments and physician evaluations toproduce a risk profile of the patient, continuously track its clinicaltrajectory, and provide decision support to clinicians as regarding whento schedule a visit or additional tests.

System Modules and Interaction

Referring now to the Figures, FIG. 1 illustrates a medical care riskbased monitoring environment 1010 for providing health providers, suchas physicians, nurses, or other medical care providers, risk-basedmonitoring in accordance with various embodiments of the presentdisclosure. A patient 101 may be coupled to one or more physiologicalsensors or bedside monitors 102 that may monitor various physiologicalparameters of the patient. These physiological sensors may include butare not limited to, a blood oximeter, a blood pressure measurementdevice, a pulse measurement device, a glucose measuring device, one ormore analyte measuring devices, an electrocardiogram recording device,amongst others. In addition, the patient may be administered routineexams and tests and the data stored in an electronic medical record(EMR) 103. The electronic medical record 103 may include but is notlimited to stored information such as hemoglobin, arterial and venousoxygen content, lactic acid, weight, age, sex, ICD-9 code, capillaryrefill time, subjective clinician observations, patientself-evaluations, prescribed medications, medications regiments,genetics, etc. In addition, the patient 101 may be coupled to one ormore treatment devices 104 that are configured to administer treatmentsto the patient. In various embodiments, the treatments devices 104 mayinclude extracorporeal membrane oxygenator, ventilator, medicationinfusion pumps, etc.

By way of the present disclosure, the patient 101 may be affordedimproved risk-based monitoring over existing methods. A patient specificrisk-based monitoring system, generally referred to herein as system100, may be configured to receive patient related information, includingreal-time information from bed-side monitors 102, EMR patientinformation from electronic medical record 103, information fromtreatment devices 104, such as settings, infusion rates, types ofmedications, and other patient related information, which may includethe patient's medical history, previous treatment plans, results fromprevious and present lab work, allergy information, predispositions tovarious conditions, and any other information that may be deemedrelevant to make an informed assessment of the possible patientconditions and states, and their associated probabilities. For the sakeof simplicity, the various types of information listed above willgenerally be referred to hereinafter as “patient-specific information”.In addition, the system may be configured to utilize the receivedinformation, determine the clinical risks, which then can be presentedto a medical care provider, including but not limited to a physician,nurse, or other type of clinician.

The system, in various embodiments, includes one or more of thefollowing: a processor 111, a memory 112 coupled to the processor 111,and a network interface 113 configured to enable the system tocommunicate with other devices over a network. In addition, the systemmay include a risk-based monitoring application 1020 that may includecomputer-executable instructions, which when executed by the processor111, cause the system to be able to afford risk based monitoring of thepatients, such as the patient 101.

The risk based monitoring application 1020 includes, for example, a datareception module 121, a physiology observer module 122, a clinicaltrajectory interpreter module 123, and a visualization and userinteraction module 124. In an exemplary embodiment, the data receptionmodule 121 may be configured to receive data from bedside monitors 102,electronic medical records 103, treatment devices 104, and any otherinformation that may be deemed relevant to make an informed assessmentregarding the patient's clinical risks, and any combination thereof ofthe preceding elements.

The physiology observer module 122 utilizes multiple measurements toestimate probability density functions (PDF) of internal state variables(ISVs) that describe the components of the physiology relevant to thepatient treatment and condition in accordance with a predefinedphysiology model. The ISVs may be directly observable with noise (as anon-limiting example, heart rate is a directly observable ISV), hidden(as a non-limiting example, oxygen delivery (DO₂) defined as the flow ofblood saturated oxygen through the aorta cannot be directly measured andis thus hidden), or measured intermittently (as a non-limiting example,hemoglobin concentration as measured from Complete Blood Count tests isan intermittently observable ISV).

In one embodiment, instead of assuming that all variables can beestimated deterministically without error, the physiology observermodule 122 of the present disclosure provides probability densityfunctions as an output. Additional details related to the physiologyobserver module 122 are provided herein.

The clinical trajectory interpreter module 123 may be configured, forexample, with multiple possible patient states, and may determine whichof those patient states are probable and with what probability, giventhe estimated probability density functions of the internal statevariables. A patient state is defined as a qualitative description ofthe physiology at a particular point of a clinical trajectory, which isrecognizable by medical practice, and may have implications to clinicaldecision-making. Examples of particular patient states include, but arenot limited to, hypotension with sinus tachycardia, hypoxia withmyocardial depression, compensated circulatory shock, cardiac arrest,hemorrhage, amongst others. In addition, these patient states may bespecific to a particular medical condition, and the bounds of each ofthe patient states may be defined by threshold values of variousphysiological variables and data. In various embodiments, the clinicaltrajectory interpreter module 123 may determine the patient conditionsunder which a patient may be categorized using any of informationgathered from reference materials, information provided by health careproviders, other sources of information. The reference materials may bestored in a database or other storage device 130 that is accessible tothe risk based monitoring application 1020 via network interface 113,for example. These reference materials may include material synthesizedfrom reference books, medical literature, surveys of experts, physicianprovided information, and any other material that may be used as areference for providing medical care to patients. In some embodiments,the clinical trajectory interpreter module 123 may first identify apatient population that is similar to the subject patient beingmonitored. By doing so, the clinical trajectory interpreter module 123may be able to use relevant historical data based on the identifiedpatient population to help determine the possible patient states.

The clinical trajectory interpreter module 123 is capable of alsodetermining the probable patient states under which the patient can becurrently categorized, given the estimated probability density functionsof the internal state variables, as provided by physiology observermodule 122. In this way, each of the possible patient states is assigneda probability value from 0 to 1. The combination of patient states andtheir probabilities is defined as the clinical risk to the patient.Additional details related to the clinical trajectory interpreter module123 are provided herein.

Visualization and user interactions module 124 may be equipped to takethe outputs of the data reception module 121 the physiology observermodule 122, and the clinical trajectory interpreter module 123 andpresent them to the clinical personnel. The visualization and userinteractions module 124 may show the current patient risks, theirevolution through time, the probability density functions of theinternal state variables as functions of time, and other features thatare calculated by the two modules 122 and 123 as by-products and areinformative to medical practice. Additionally, visualization and userinteractions module 124 enables the users to set alarms based on thepatient state probabilities, share those alarms with other users, takenotes related to the patient risks and share those notes with otherusers, and browse other elements of the patient medical history.Additional details related to the visualization and user interactionsmodule 124 are provided herein.

Physiology Observer

FIG. 2 illustrates a basic schematic of the physiology observer module122, which utilizes two models of the patient physiology: a dynamicmodel 212 and an observation model 221. The dynamic model 212 capturesthe relationship arising between the internal state variables at sometime t_(k) and another close time t_(k+1), thereby enabling modeling ofthe patient physiology as a system whose present state has informationabout the possible future evolutions of the system. Given the propensityof the patient physiology to remain at homeostasis throughauto-regulation, there is a clear rational of introducing such memory ininternal state variables that are indicative of the homeostasis, e.g.,oxygen delivery and oxygen consumption.

The observation model 221 may capture the relationships between measuredphysiology variables and other internal state variables. Examples ofsuch models include: a) the dependence of the difference betweensystolic and diastolic arterial blood pressures (also called pulsepressure) on the stroke volume; b) the relationship between heart rate,stroke volume, and cardiac output; c) the relationship betweenhemoglobin concentration, cardiac output and oxygen delivery; d) therelationship between the Vanderbilt Assessment Scale and the clinicalstate of an attention deficit and hyperactivity disorder patient; and e)any other dependence between measurable and therefore observableparameters and internal state variables.

The physiology observer module 122 functions as a recursive filter byemploying information from previous measurements to generate predictionsof the internal state variables and the likelihood of probable futuremeasurements and then comparing them with the most recently acquiredmeasurements. Specifically the physiology observer module 122 utilizesthe dynamic model 212 in the predict step or mode 210 and theobservation model 221 in the update step or mode 220. During theprediction mode 210, the physiology observer module 122 takes theestimated PDFs of ISVs 213 at a current time step t_(k) and feeds themto the dynamic model 212, which produces predictions of the ISVs 211 forthe next time step t_(k+1). The is accomplished using the followingequation:

P(ISVs(t _(k+1))|M(t _(k)))=∫_(ISVsϵISV) P(ISVs(t _(k+1))|ISVs(t_(k)))P(ISVs(t _(k))|M(t _(k)))dISVs.

where ISVs(t_(k))={ISV₁(t_(k)), ISV₂(t_(k)), ISV₃(t_(k)), . . .ISV_(n)(t_(k))} and M(t_(k)) is the set of all measurements up to timet_(k). The probability P(t_(k)+1)|ISVs(t_(k))) defines a transitionprobability kernel describing the dynamic model 212, which defines howthe estimated PDFs evolve with time. The probabilitiesP(ISVs(t_(k))|M(t_(k))) are provided by the inference engine 222 and arethe posterior probabilities of the ISVs given the measurements acquiredat the previous time step. During the update mode 210 of the physiologyobserver module 122, the predicted ISVs 211 are compared against thereceived measurements from data reception module 121 with the help ofthe observation model 221, and as a result the ISVs are updated toreflect the new available information. The inference engine 222 ofmodule 122 achieves this update by using the predicted PDFs as a-prioriprobabilities, which are updated with the statistics of the measurementsto achieve the posterior probabilities reflecting the current ISVs PDFsestimates 213. The inference engine 222 accomplished the update step 220with the following equation which is Bayes' Theorem,

${P\left( {{{ISVs}\left( t_{k + 1} \right)}{M\left( t_{k + 1} \right)}} \right)} = \frac{P\left( {{m_{1}\left( t_{k + 1} \right)},{m_{2}\left( t_{k + 1} \right)},{{\ldots \mspace{11mu} {m_{n}\left( t_{k + 1} \right)}}{{{ISVs}\left( t_{k + 1} \right)}{M\left( t_{k} \right)}}}} \right)}{P\left( {M\left( t_{k + 1} \right)} \right)}$

where P(m₁(t_(k+1)),m₂(t_(k+1)), . . . m_(n)(t_(k+1))|ISVs(t_(k+1))) isthe conditional likelihood kernel provided by the observation model 221that determines how likely the currently received measurements are giventhe currently predicted ISVs.

At the initialization time, e.g., t=0, when no current estimate of ISVsPDFs is available, the physiology observer module 122 may utilizeinitial estimates 250, which may be derived from an educated guess ofpossible values for the ISVs or statistical analysis of previouslycollected patient data.

FIG. 3 illustrates a non-limiting example of models that enable thephysiology observer in accordance with the present disclosure. While notdirectly observable, the management of oxygen delivery, DO2, is animportant part of critical care. Therefore, precise estimation of DO2can inform improved clinical practice. In the illustrated example, thisestimation is achieved through the measurements of hemoglobinconcentration (Hg), heart rate (HR), diastolic and systolic arterialblood pressures, and SpO2. The dynamic model 212 assumes that oxygendelivery is driven by a feedback process which stabilizes it againststochastic disturbances. Similarly, hemoglobin concentration iscontrolled around the norm value of 15 mg/dL. The observation model 221takes into account the relationship between arterial oxygen saturationSpO2, hemoglobin concentration and arterial oxygen content CaO2, thedependence of the difference between systolic, ABPs, and diastolic,ABPd, arterial blood pressures (also called pulse pressure) on thestroke volume, and the relationship between heart rate, HR, strokevolume, SV, and cardiac output. The two models are abstracted as aDynamic Bayesian Network (DBN), and the physiology observer module 122utilizes the DBN to continuously track the oxygen delivery. A DynamicBayesian Network is a systematic way to represent statisticaldependencies in terms of a graph whose vertices signify variables(observable and unobservable), and whose edges show causalrelationships. Further descriptions of an exemplary DBN for DO2estimation can be found in U.S. Provisional Application No. 61/699,492,filed on Sep. 11, 2012, entitled SYSTEMS AND METHODS FOR EVALUATINGCLINICAL TRAJECTORIES AND TREATMENT STRATEGIES FOR OUTPATIENT CARE,Attorney Docket No. 3816/1003, and U.S. Provisional Application No.61/684,241, filed on Aug. 17, 2012, entitled SYSTEM AND METHODS FORPROVIDING RISK ASSESSMENT IN ASSISTING CLINICIANS WITH EFFICIENT ANDEFFECTIVE BLOOD MANAGEMENT, Attorney Docket No. 3816/1001, to whichpriority is claimed, the disclosure of which is incorporated herein byreference.

FIG. 4 depicts a non-limiting example of the physiology observerdescribed above tracking DO2, but over a longer time interval, i.e., 4time steps. In the observer, the main hidden ISV is the oxygen deliveryvariable (DO2). The two types of measurements, Hemoglobin (Hg) andoximetry (SpO2) are in dashed circles in FIG. 4. SpO2 is an example ofthe continuous or periodic measurements that the physiology observermodule 122 receives from sensors, such as bedside monitors 102 andtreatment devices 104 connected to the patient 101 that continuouslyreport information. Hemoglobin (Hg) is an example of an intermittent oraperiodic measurement extracted from patient lab work that is availableto the observer on a sporadic and irregular basis, and latent at times,relative to current system time. The physiology observer module 122 iscapable of handling both types of measurements because, along withtracking the hidden ISVs, e.g. DO2, module 122 also continuouslymaintains estimates of the observed values for all types ofmeasurements, even when measurements are not present. FIG. 4 depictsthese estimates for the case of SpO2 and Hg. As can be seen, the SpO2measurements are available regularly at each time step, whereas Hg isonly available at two of the time steps.

As mentioned above, certain measurements, such as Hemoglobin, areavailable to the system with an unknown amount of time latency, meaningthe measurements are valid in the past relative to the current time andthe time they arrive over the data communication links. The physiologyobserver module 122 may handle such out of sequence measurements usingback propagation, in which the current estimates of the ISVs areprojected back in time to the time of validity of the measurements, sothat the information from the latent measurement can be incorporatedcorrectly. FIG. 5 depicts such time line. In FIG. 5, hemoglobin arrivesat the current system time, t_(k), but is valid and associated back tothe ISV (DO2) at time T_(k−2). Back propagation is the method ofupdating the current ISVs probability estimates P(ISVs(t_(k))|M(t_(k)))with a measurement that is latent relative to the current time,m(t_(k−n)) Back propagation is accomplished in a similar manner to theprediction method described previously. There is a transitionprobability kernel, P(ISVs(t_(k−n))|ISVs(t_(k))), that defines how thecurrent probabilities evolve backwards in time. This can then be used tocompute probabilities of the ISVs at time t_(k−n) given the current setof measurements which excludes the latent measurement, as follows:

P(ISVs(t _(k−n))|M(t _(k)))=∫_(ISVs∈ISV) P(ISVs(t _(k−n))|ISVs(t_(k)))P(ISVs(t _(k))|M(t _(k)))dISVs.

Once these probabilities are computed, the latent measurementinformation is incorporated using Bayes' rule in the standard update:

${P\left( {{{{ISVs}\left( t_{k - n} \right)}{M\left( t_{k} \right)}},{m\left( t_{k - n} \right)}} \right)} = \frac{{P\left( {{m\left( t_{k - n} \right)}{{ISVs}\left( t_{k - n} \right)}} \right)}{P\left( {{{ISVs}\left( t_{k - n} \right)}{M\left( t_{k} \right)}} \right.}}{P\left( {{M\left( t_{k} \right)},{m\left( t_{k - n} \right)}} \right)}$

The updated probabilities are then propagated back to the current timet_(k) using the prediction step described earlier. Back propagation canbe used to incorporate the information.

Another functionality of the physiology observer module 122 includessmoothing. The care provider using the system 100 may be interested inthe patient state at some past time. With smoothing, the physiologyobserver module 122 may provide a more accurate estimate of the patientISVs at that time in the past by incorporating all of the newmeasurements that the system has received since that time, consequentlyproviding a better estimate than the original filtered estimate of theoverall patient state at that time to the user, computingP(ISVs(t_(k−n))|M(t_(k))). This is accomplished using the first step ofback propagation in which the probability estimates at time t_(k) whichincorporate all measurements up to that time are evolved backwards tothe time of interest t_(k−n) using the defined transition probabilitykernel. This is also depicted in FIG. 5, in which the user is interestedin the patient state at t_(k−n) and the estimates are smoothed back tothat time.

Because physiology observer module 122 maintains estimates of each ofthe measurements available to the system 100 based on physiologic andstatistical models, module 122 may filter artifacts of the measurementsthat are unrelated to the actual information contained in themeasurements. This is performed by comparing the newly acquiredmeasurements with the predicted likelihoods of probable measurementsgiven the previous measurements. If the new measurements are consideredhighly unlikely by the model, they are not incorporated in theestimation. The process of comparing the measurements with theirpredicted likelihoods effectively filters artifacts and reduces noise.FIG. 6 shows an example of such a process involving mean arterial bloodpressure (ABPm). Because ABPm is collected using an intravenouscatheter, the measured signals are often corrupted with artifacts thatresult in incorrect measurements when the catheter is used for medicalprocedures such as blood draws or line flushes. FIG. 6 shows the rawABPm measurements prior to being processed by the physiology observerwith the measurement artifacts identified, as well as the filteredmeasurements after being processed by the physiology observer module122. As can be seen, the measurement artifacts have been removed and thetrue signal is left.

In various embodiments, physiology observer module 122 may utilize anumber of algorithms for estimation or inference. Depending on thephysiology model used, the physiology observer module 122 may use exactinference schemes, such as the Junction Tree algorithm, or approximateinference schemes using Monte Carlo sampling such as a particle filter,or a Gaussian approximation algorithms such as a Kalman Filter or any ofits variants.

As discussed, the physiology model used by physiology observer module122 may be implemented using a probabilistic framework known as aDynamic Bayesian Network, which graphically captures the causal andprobabilistic relationship between the ISVs of the system, both at asingle instance of time and over time. Because of the flexibility thistype of model representation affords, the physiology observer module 122may utilize a number of different inference algorithms. The choice ofalgorithm is dependent on the specifics of the physiology model used,the accuracy of the inference required by the application, and thecomputational resources available to the system. Used in this case,accuracy refers to whether or not an exact or approximate inferencescheme is used. If the physiology observer model is of limitedcomplexity, then an exact inference algorithm may be feasible to use. Inother cases, for more complex physiology observer models, no closed forminference solution exists, or if one does exist, it is notcomputationally tractable given the available resources. In this case,an approximate inference scheme may be used.

The simplest case in which exact inference may be used, is when all ofthe ISVs in the physiology model are continuous variables, andrelationships between the ISVs in the model are restricted to linearGaussian relationships. In this case, a standard Kalman Filter algorithmcan be used to perform the inference. With such algorithm, theprobability density function over the ISVs is a multivariate Gaussiandistribution and is represented with a mean and covariance matrix.

When all of the ISV's in the model are discrete variables, and thestructure of the graph is restricted to a chain or tree, the physiologyobserver module 122 may use either a Forward-backward algorithm, or aBelief Propagation algorithm for inference, respectively. The JunctionTree algorithm is a generalization of these two algorithms that can beused regardless of the underlying graph structure, and so the physiologyobserver module 122 may also use this algorithm for inference. JunctionTree algorithm comes with additional computational costs that may not beacceptable for the application. In the case of discrete variables, theprobability distribution functions can be represented in a tabular form.It should be noted that in the case where the model consists of onlycontinuous variables with linear Gaussian relationships, thesealgorithms may also be used for inference, but since it can be shownthat in this case these algorithms are equivalent to the Kalman Filter,the |Kalman Filter is used|[hc1] the example algorithm.

When the physiology model consists of both continuous and discrete ISVswith nonlinear relationships between the variables, no exact inferencesolution is possible. In this case, the physiology observer module 122may use an approximate inference scheme that relies on samplingtechniques. The simplest version of this type of algorithm is a ParticleFilter algorithm, which uses Sequential Importance Sampling. MarkovChain Monte Carlo (MCMC) Sampling methods may also be used for moreefficient sampling. Given complex and non-linear physiologicrelationships, this type of approximate inference scheme affords themost flexibility. A person reasonably skilled in the relevant arts willrecognize that the model and the inference schemes employed by thephysiology observer module may be any combination of the above describedor include other equivalent modeling and inference techniques.

When using particle filtering methods, a resampling scheme is necessaryto avoid particle degeneracy. The physiology observer may utilize anadaptive resampling scheme. As described in detail below, regions of theISV state space may be associated with different patient states, anddifferent levels of hazard to the patient. The higher the number, themore hazardous that particular condition is to the patient's health. Inorder to ensure accurate estimation of the probability of a particularpatient condition, it may be necessary to have sufficient number ofsampled particles in the region. It may be most important to maintainaccurate estimates of the probability of regions with high hazard leveland so the adaptive resampling approach guarantees sufficient particleswill be sampled in high hazard regions of the state space. FIG. 7illustrates an example of this resampling. State 1 and State 2 have thehighest hazard level. The left plot depicts the samples generated fromthe standard resampling. Notice there are naturally more particles instate 1 and state 2 region because these states are most probable. Theright plot shows the impact of the adaptive resampling. Notice how thenumber of samples in the areas of highest risk has increasedsignificantly.

Clinical Trajectory Interpreter

Referring now to FIG. 8, the Clinical Trajectory Interpreter 123 takesthe joint Probability Density Functions of the ISVs from physiologyobserver module 122, and performs state probability estimation 801 tocalculate the probabilities of different patient states. The ProbabilityDensity Functions of the ISVs may be defined in closed form, for examplemultidimensional Gaussians 260, or approximated by histogram 280 ofparticles 270, as illustrated in FIGS. 2B-D. In both cases, theprobability density functions of the ISVs can be referred to as:P(ISV1(t), ISV2(t), . . . , ISVn(t)), where t is the time they refer to.Given the internal state variables the patient state may be defined by aconditional probability density function:

P(S|ISV1,SV2, . . . ,ISVn), where S∈S ₁ ,S ₂ , . . . ,S _(N) representsall possible patient states S _(i)

Then determining the probability of the patient being in a particularstate S_(i) may be performed by the equation:

P(S _(i)(t))=∫_(−∞) ^(∞). . . ∫_(−∞) ^(∞) P(S|ISV₁ ,ISV ₂ , . . . ,ISV_(n))P(ISV ₁(t),ISV ₂(t), . . . ,ISV _(n)(t))dISV₁ . . . dISV_(n)

In case that P(ISV1(t), ISV2(t), . . . , ISVn(t)) is defined by a closedform function such as multidimensional Gaussian 260, the integration maybe performed directly. In case that P(ISV1(t), ISV2(t), . . . , ISVn(t)is approximated by a histogram 280 of particles 270 and P(S|ISV₁, ISV₂,. . . , ISV_(n)) is defined by a partition of the space spanned by ISV₁,ISV₂, . . . , ISV_(n) n into regions as shown in FIG. 9, the probabilityP(S_(i)(t)) may be calculated by calculating the fraction of particles270 in each region.

Once patient state probabilities are estimated, the clinical trajectoryinterpreter module 123 may assign different hazard levels 802 for eachpatient state or organize the states into different etiologies 803. Theclinical trajectory interpreter module 123, in conjunction with thephysiology observer module 122, may perform measurements utilitydetermination 804 to determine the utility of different invasivemeasurements such as invasive blood pressures or invasive oxygensaturation monitoring. In one embodiment, the Clinical trajectoryinterpreter Module 123 determines the probabilities that the patient isin a particular state, rather than the exact state that the patient isin.

FIG. 9 illustrates a non-limiting example of a definition of a patientstate that may be employed by the clinical trajectory interpreter module123. Specifically, it assumes that the function P(S|ISV₁, ISV₂, . . . ,ISV_(n)) may be defined by partitioning the domain spanned by theinternal state variables ISV₁, ISV₂, . . . , ISV_(n). The particularexample assumes that the patient physiology is described by two internalstate variables: Pulmonary Vascular Resistance (PVR) and Cardiac Output(CO). The particular risks and respective etiologies that may becaptured by these two ISVs emanate from the effects of increasedpulmonary vascular resistance on the circulation. Specifically, high PVRmay cause right-heart failure and consequently reduced cardiac output.Therefore, PVR can be used to define the attributes of Normal PVR andHigh PVR, and CO to define the attributes of Normal CO and Low CO, byassigning thresholds with the two variables. By combining theseattributed, four separate states can be defined: State 1: Low CO, NormalPVR; State 2: Low CO, High PVR; State 3: Normal CO, High PVR; State 4:Normal CO Normal PVR.

FIG. 10 illustrates a non-limiting example of how the clinicaltrajectory interpreter module 123 may employ the definition of patientstates to assign probabilities that the patient may be classified undereach of the four possible patient states at a particular point of time.In the example, the clinical trajectory interpreter module 123 takes thejoint probability density function of P(Cardiac Output (Tk), PulmonaryVascular Resistance (Tk)) and integrates it over the regionscorresponding to each particular state, which produces P(S1(Tk)),P(S2(Tk)), P(S3(Tk)), and P(S4(Tk)). In this way, the clinicaltrajectory interpreter module 123 assigns a probability that aparticular patient state is ongoing, given the information provided bythe physiology observer module 122. Note that if the output of thephysiology observer module 122 is not a closed form function 260 but ahistogram 280 of particles 270, the clinical interpreter will notperform integration but just calculate the relative fraction ofparticles 270 within each region.

FIG. 11 illustrates an alternative approach of estimating theprobabilities for different patient states. In this alternativeapproach, to calculate the probabilities P(S1), P(S2), P(S3) and P(S4),the clinical trajectory interpreter module 123 employs the jointprobability functions of the ISVs for two consecutive time windows T_(k)and T_(k+1) to calculate a moving window average. Note in the examplethat the size of the window is doubled for two time instances, whichindicates that the window may be of an arbitrary, suitable size. As aresult of this moving window averaging, the clinical trajectoryinterpreter module 123 performs a dynamic analysis of the trajectory ofthe ISVs. That is, it gives a metric of the probability that thephysiology trajectory, as described by the ISVs, may be found in aparticular region in a particular time frame. In other words, thisprobability calculation gives an estimate of the probability that aparticular patient state may be ongoing in the chosen time-frame, asopposed to just at a chosen time instance.

Clinical trajectory interpreter module 123 may also assign hazard levelsto each particular state. FIG. 12 illustrates a non-limiting example ofa definition of patient states assigned with hazard levels by theclinical trajectory interpreter module 123. The hazard levels may beinformed from clinician surveys, reference literature or any otherclinical sources. In the particular example, the clinical trajectoryinterpreter module 123 distinguishes between four different hazardlevels: 1—Minimal risk, 2—Mild risk, 3—Medium risk, and 4—Severe risk.The combination of the probability of a patient state and its hazardlevel will be referred from hereon as a “Patient risk.”

FIG. 13 illustrates how the patient states and their respectiveprobabilities may be organized into tree graphs called etiologies. Inparticular, the attributes normal and low associated with the cardiacoutput ISV are the base nodes of the graph. Each of these vertexes hastwo children associated with the attributes of the pulmonary vascularresistance. This organization leads to each patient state being a leaf(end vertex) on the tree. This particular tree will be referred to as anetiology tree. The etiology tree may be further employed by thevisualization and user interaction module 124 to provide a layered viewof the various patient risks as further described herein.

FIG. 14 illustrates that the etiology tree may not be unique for a givenset of patient states and physiologic variables. Specifically, FIG. 14provides an alternative etiology tree for the example from FIG. 13. Theroot of the alternative etiology tree starts from the attributesassociated with the pulmonary vascular resistance, instead of theattributes associated with cardiac output. It can be appreciated thatdifferent rules may be employed for generating the trees depending onvarious factors and the context of use. For example, one etiology treemay be preferred against another realization in different clinicalsituations or depending on the preference of the users. Moreover, thetree may dynamically change as the risks change and the clinicalsituation evolves.

Utility of Different Measurements

During hospital care, there exist measurements that may harm the patientor slow down their recovery. Examples of such harmful measurements areall measurements coming from catheters such as invasive blood pressuresand blood oximetry, which have been shown to significantly increase therisk of infection. Therefore, it may be useful if, during the careprocess, the clinician is provided with an assessment of the utility ofeach of the potentially harmful measurements. FIG. 15 illustrates amethod for calculating the utility of different measurements.

Referring to FIG. 15, the risk-based system 100 and the clinicaltrajectory interpreter module 123 may calculate the utility of aparticular measurement with the illustrated procedure. Particularly, instep 9001, a measurement m_(i) may be selected. Given measurement m_(i)and a current time (t_(current)), in step 9002, the clinical trajectoryinterpreter module 123 may submit an instruction to the physiologyobserver module 122 to simulate the physiology observer module output(the probability density functions of the internal state variables) froma given arbitrary point back from the current time a (t_(current)-T) tothe current time t_(current) with removal of measurement m_(i) from thealgorithm output. Then, in step 9003, the clinical trajectoryinterpreter module 123 may simulate the state probabilities estimationgiven the simulated output of the physiology observer and arrive with aset of patient state probabilities, i.e., P_(sim)(S₁(t_(current))),P_(sim)(S₂(t_(current))), . . . , P_(sim)(S_(n)(t_(current))). Then, instep 9004, using the state probabilities determined from all availablemeasurements, i.e., P(S₁(t_(current))), P(S₂(t_(current))), . . . ,P(S_(n)(t_(current))), the clinical trajectory interpreter module 123may calculate the utility of the measurement m_(i) using the formula:

${{U\left( m_{i} \right)} = {{D\left( P_{sim} \middle| P \right)} = {\sum\limits_{i = 1}^{n}{{P\left( {S_{i}\left( t_{current} \right)} \right)}{\log \left( \frac{P\left( {S_{i}\left( t_{current} \right)} \right)}{P_{sim}\left( {S_{i}\left( t_{current} \right)} \right)} \right)}}}}},$

which is also the Kullback-Leibler divergence between the patient statedistribution given all available measurements and the patient statedistribution given the measurement m_(i) has been removed for a timeinterval T.

Alternatively, in step 9005, the clinical trajectory interpreter module123 may calculate utility for m_(i) by employing the hazard levels,r_(i), assigned to each state S_(i) by the formula:

${U\left( m_{i} \right)} = {{D_{weighted}\left( P_{sim} \middle| P \right)} = {\sum\limits_{i = 1}^{n}{r_{i}{P\left( {S_{i}\left( t_{current} \right)} \right)}{{\log \left( \frac{P\left( {S_{i}\left( t_{current} \right)} \right)}{P_{sim}\left( {S_{i}\left( t_{current} \right)} \right)} \right)}.}}}}$

In a similar manner, the clinical trajectory interpreter module 123 canperform the utility calculation not only for a particular measurement,but also for any group of measurements. The utility calculation can alsoinclude a component that captures the potential harm associated with aparticular measurement. For example, the invasive catheter measurementdescribed above would have a large level of harm associated with it. Inthis way, the calculation trades the harm associated with themeasurement against the value of information it provides. An example ofthis modified utility calculation is given by the following formula:

U(m ₁)=D _(weighted)(P _(sim) |P)−H(m _(i)),

where H(m_(i)) defines a function that describes the harm of eachavailable measure.

The risk-based monitoring system 100 can also integrate externalcomputation generated from third party algorithms implemented either onthe same computation medium as the patient-based monitoring system or asa part of an external device. FIG. 16 illustrates one possiblerealization of integration of an external computation generated fromthird party algorithms. Particularly, the output from the externalcomputation 9110 is provided to the clinical trajectory interpretermodule 123 which implements integration instructions 9120. As a resultthe state probability estimation 801 produces new states P(newS₁),P(newS₂), P(newS₃), . . . , P(newS_(n+m)), which may result in anincreased number of states n+m from the original number of n states.Similarly, integration instructions 9120 may be provided to the hazardlevel assignment 802 and the etiology organization 803.

FIG. 17 illustrates an example of integration instructions. In theexample, it is assumed that the external computation, EC, providesinformation about particular binary attributes A=a₁ or A=a₂, and thespecific of how the provided information is captured in the integrationinstructions by the conditional probability P(EC|A). Also, given fouroriginal states S₁, S₂, S₃, and S₄, the integration instruction mayspecify how the states S₃ and S₄ may be updated with two additionalattributes A=a₁ and A=a₂, and turn into four new states newS₃, newS₄,newS₅, and newS₆. To perform this update, the integration instructionmay also employ prior probabilities P(A|S₃) and P(A|S₄). These priorprobabilities may be derived from retrospective studies by analyzingwhat fractions of patients exhibiting S₃ or S₄ have concomitantlyexhibited A=a₁ or A=a₂.

Another way to derive the prior probabilities is by soliciting theopinion of clinicians.

By utilizing the integration instructions, the state probabilitiesestimation 801 of the new states may then be derived from the formula:

P(A=a _(j) ,S _(i) |EC)=P(EC|A=a _(j))P(A=a _(j) |S _(i))P(S_(j))/P(EC),

where i in {3,4} and j in {1,2}, and where P(S_(j)) are the originalpatient state probabilities derived from the output of the physiologyobserver module 122.

FIG. 18 illustrates an additional example of integration instructions ofan external computation. Again, the risk-based monitoring system 100 canperform the integration, as shown in FIG. 18, both in the case that theexternal computation 9110 is generated on the same computational mediumas the patient-based monitoring system, or as a part of an externaldevice. In this case, it is assumed that the external computation 9110provides direct information about a particular internal state variableestimated by the physiology observer module 122 (or enhanced physiologyobserver module 9300). Therefore, to integrate the external computation,the physiology observer module 122 can treat the external computation9110 as an additional measurement and integrate it directly into theobservation model 221.

Visualization and User Interaction|[DB2]

FIG. 19 illustrates example functionalities of the visualization anduser interactions module 124. Specifically, module 124 may receive allavailable patient information and data including, the data from the datareception module 121, the joint probability density function produced bythe physiology observer module 122, and the etiology tree, the risks,and the invasive measurements utilities estimated by the clinicaltrajectory interpreter module 123. By utilizing this information, thevisualization and user interactions module 124 may produce: 1) a unitview 1501 of patients describing their risks, diagnoses, etc.; 2) a view1502 of a patient's electronic medical record including laboratoryresults, prescribed medication, diagnoses, etc.; 3) a view 1503 of apatient's ongoing risks; 4) a view 1504 of a patient's risk trajectory,i.e., how the probabilities for particular patient states have evolvedin a particular time frame; 5) a view 1505 of a patient's measurementsutilities in the estimation of the particular patient risks; 6) a plotof a patient estimated ISVs' PDFs 1506 describing the time evolution ofthe ISVs' PDFs; 7) a view 1507 enabling to navigate through the etiologytree of the patient and thus visualize different levels of the tree; 8)a view 1508 showing a patient's predicted risks; 9) a view 1509 enablingclinicians to view and set patient risk based alarms; 10) a view 1510 ofa patient's physiology monitoring data and its evolution against time;and 11) any combination of the above described. In addition, thevisualization and user interactions module 124 may also produce apatient tags view 1511, a patient condition summary 1512, reference andtraining material 1513, and annotation and tag setting 1514.

FIG. 20 illustrates an example of a summary view 2000 that may convey ina single screen a risk profile for each patient in a particular hospitalunit. The risk profile represents what is the cumulative probability ofthe patient being in a particular hazard level. It is calculated bysumming the current probabilities of all states at particular hazardlevel. In the example, the summed probabilities, hazard levels arerepresented by the height of four bars, each bar corresponding to aparticular hazard level. In this specific example, these hazard levelsmay be Green (slanted hatching)—Minimal risk, Yellow (verticalhatching)—Mild risk, Orange (horizontal hatching)—Medium risk, and Red(dotted hatching)—Severe risk.

FIG. 21 illustrates one possible realization of a view 2100 describingthe ongoing risks of the patient. Each round-cornered box corresponds toa particular risk: the color corresponds to the hazard level with Green(slanted hatching)—Minimal risk, Yellow (vertical hatching)—Mild risk,Orange (horizontal hatching)—Medium risk, and Red (dottedhatching)—Severe risk; the height of the box corresponds to theprobability of the particular patient state. Risks are grouped incolumns based on their hazard levels. The screen and the respectiverisks are updated in real-time as new data becomes available.

Still referring to FIG. 21, in addition to the visualization of theongoing patient risks, the system 100 may provide information about theutility of the various invasive measurements in determining these risks.Specifically, the illustrated example gives the utilities of invasivearterial blood pressure (ABP) and invasive central venous pressure (CVP)measurements. The utility may be represented by filled bars 2110 and2120, and the maximum utility may correspond to six filled bars. The sixfilled bars may be displayed in color gradient from 1—dark green,2—light green, 3—yellow, 4—red, 5—purple, to 6—white or empty. In thisparticular embodiment, the filled bars 2110 for ABP show all six colors,while two of the filled bars 2120 for CVP respectfully show 1-dark greenand 2-light green and the remaining filled bars 2110 show 6-white orempty.

FIG. 22 illustrates a view 2200 and how a slider 2210 or other graphicelement on top of the patient view may be utilized in reviewing thehistory of the patient risks. Specifically, in the example, the slider2210 is moved to show the patient risks at approximately four hours backfrom current time. This enables clinicians to review the continuousevolution of the patient risks and compare them with the appliedtreatment or any other external factors. In various embodiments, slider2210 may be moved on the user interface with a pointing device, acommand, or, if utilized in conjunction with touch sensitive displays,through touching and dragging the slider or other graphic element todesignate the desired time period.

Referring now to both FIGS. 21 and 22, the etiology tree is used tocombine the two states State A 2130: Hypoxia with low cardiac output andState B 2140: hypoxia with low Qp:Qs from FIG. 21 to represent them by asingle patient state (Hypoxia) 2220. In the particular example, this isused to fit the text into the smaller box of FIG. 22 relative to FIG.21. The user can navigate the etiology tree in view 2300 by clicking onthe composite patient state 2220 and viewing its constituent patientstates 2130 and 2140, as illustrated in FIG. 23.

FIG. 24 illustrates in view 2400 how in the same framework the user mayview the predicted risks for the patient by moving the slider 2410 aheadof current time. |[DB3]

FIG. 25 illustrates in view 2500 an interactive dialog box 2510 throughwhich the user may define the conditions to set an alarm for aparticular risk. The user achieves this by selecting the particular riskand then setting upper and lower thresholds for the patient stateprobability associated with this risk. No alarm is activated as long asthe patient state probability is between the upper and the lowerthreshold. The alarm is activated when the patient state probabilitycrosses the threshold. Once the alarm is activated the system 100 maynotify a list of chosen people, or send the notification to anotherclinical system. Any of module 122-124 may actually store theirrespective threshold data ranges and initiate the trigger depending onthe specific parameter.

FIG. 26 illustrates in view 2600 yet another possible visualization ofthe patient risk trajectory, i.e. the evolution of the patient states'probabilities associated with particular risks. The user may choose whattime series of patient state probabilities he/she wants to display, andthe system plots these probabilities against time.

FIG. 27 illustrates in view 2700 how the system 100 may directly presentthe probability density functions of various internal state variables.Specifically, in the example, the estimated PDF of oxygen delivery isplotted in graph 2710 as a function of time, with darker colorscorresponding to higher likelihood. Similarly, the estimated PDF ofmixed venous oxygenation saturation (SvO2) is plotted in graph 2720 andcompared with actual measurements (dark circles).

Information Sharing Among Users

FIG. 28 in view 2800 illustrates an example of a tagging definitioninterface 2810 that enables clinicians to mark specific instances oftime or specific periods of time 2820 that are of interest or representimportant points in the clinical course, i.e. a tag. Tags may be sharedor sent via dialog box 2830 to specified recipients, or may be includedin notes or any other part of the user interface. Users may be able toannotate a tag with particular comments or observations via dialog box2840, and tags may be classified into categories from menu list 2850,for example, a tag may represent a change in medication dosing, anintervention, a note regarding monitors or measuring equipment, etc.Tags and their respective time-series markings may be color coded toindicate various properties, such as their category. For example, greentag-marks on a time series may represent changes in medication, redtag-marks may represent interventions, and yellow tag marks mayrepresent periods of heightened concern. When setting a tag, the usermay be prompted to define time instance or the time period, the categoryof the tag, the annotation for the tag, and how the tag should behandled by the system. Furthermore, annotations may be suggested byusing natural language processing to convert the etiologies of thecondition into note form.

FIG. 29 illustrates in view 2900 a Newsfeed view 2910 comprising tags,notes, or information taken from external sources, such as the time of ablood draw as taken from an electronic medical record (EMR). TheNewsfeed 2910 may allow clinicians to view and post events, periods ofinterest, interventions, notes, tags, etc., which are posted by otherclinicians. Clinicians may view the entire Newsfeed, or sort it based onTag category, hazard level, etc. Further, clinicians may search for tagsbased on keywords, intervention type, time of stay, source ofinformation, etc. Entries 2920-2926 on Newsfeed 2010 may indicate any ofthe category, source of tag, and patient overview, either in words, oras a picture, such as the risk profile.

FIG. 30 illustrates in view 3000 a Condition Summary View 3010 throughwhich the clinician may request a condition summary by selecting orclicking a particular patient state. The Condition Summary View 3010then may present clinicians with a description of a particular state,including both definitions in window 3020 of the state, and informationregarding how the system arrived at the conclusion about this patientstate probability. This view 3010 may provide the likelihood and hazardlevel of the patient state, the definition of the patient state in termsof ISV thresholds, and the likelihood of each attribute defining thestate, as illustrated and can also provide a natural languagedescription and evidence window 3030 of evidence contributing to thepatient state, by translating the ISVs PDFs into a qualitative textualdescription, or by directly presenting numerical information regardingthe evidence. As an example, FIG. 30 illustrates the Condition SummaryView 3010 for the patient state shock due to low cardiac output. Here,the Condition Summary View 3010 presents the probability of the “shockdue to low cardiac output” state, and the hazard level of the stateshown in color or dotted hatching. Further, the definitions of shock(mixed venous saturation below or equal to 45%), and low cardiac output(cardiac output below 3.2 liters per minute per meter squared), alongwith the probabilities that each of these are satisfied (e.g., 40% forshock and 30% for low CO) is presented. The evidence window 3030 conveysthe information which leads to the assessment of “Shock due to low CO”.In this example, the system has converted the information regarding theprobabilities of the etiologies into a textual form, specifically thatthe estimated probability is mainly driven by the fact that there is subnominal pulse pressure (systolic blood pressure minus diastolic bloodpressure) indicating reduced stroke volume.

FIG. 31 further illustrates in view 3100 the ability for the userinterface to include and display reference material, which may beaccessed through the Internet, or stored within the system 100 orremotely accessible thereby. Selecting the Learn More button 3110 in theCondition Summary View 3010 may bring up a Learn More View 3120, whichshows reference information associated with the Condition Summary View3010. Reference information may include causes, interventions, commoncomorbidities, anatomy, relevant publications, etc. Furthermore, thisfeature may serve as a training tool to familiarize clinicians withmanaging the particular patient population, or treatment strategies.

HLHS Stage 1 Example

The following description explains how the disclosed system 100 andtechniques can be applied to the modeling of the clinical course of aspecific patient population under intensive care—post-operativelyrecovering Hypoplastic Left Heart Syndrome patients after stage onepalliation.

Hypoplastic Left Heart Syndrome is a congenital heart defect, which ismanifested by an underdeveloped left ventricle and left atrium. As aresult, patients suffering from this condition do not have separatedsystemic and pulmonary blood flows, but instead the right ventricle isresponsible for pumping blood to both the body and the lungs. Therefore,the hemodynamic optimization during intensive care involves managing thefractions of the blood flow that pass through the lungs (pulmonary flowQ_(p)) and the body (systemic flow Q_(s)). The optimal hemodynamic stateis reached when, adequate tissue oxygen delivery, DO₂, is achieved for apulmonary to systemic blood flow ratio, denoted Q_(p)/Qs, of 1. Often,to reach this optimal state, the patient physiology passes through otherless beneficial states, and the correct identification of these statesand the application of a proper treatment strategy for each one of themdefine the quality of the post-operative care.

TABLE 1 Variable Description Units Type DO₂ Indexed Oxygen Delivery mLO₂/min/m² Dynamic VO₂ Indexed Oxygen Consumption mL O₂/min/m² DynamicPVR Pulmonary Vascular Resistance mm Hg/L/min/m² Dynamic SVR SystemVascular Resistance mm Hg/L/min/m² Dynamic ΔPVR Change in PVR per timestep mm Hg/L/min/m² Dynamic ΔSVR Change in SVR per time step mmHg/L/min/m² Dynamic Hb Hemoglobin g/dL Dynamic/Observed HR Heart RateBeats per min Dynamic/Observed SpvO₂ Pulmonary Venous Oxygen Saturation% Dynamic SaO₂ Arterial Oxygen Saturation % Derived/Observed SvO₂Systemic Venous Oxygen Saturation % Derived/Observed SpO₂ PulmonaryVenous Oxygen Saturation % Observed η Aortic Compliance Dynamic ABPmMean Arterial Blood Pressure mm Hg Derived/Observed CVP Central VenousPressure mm Hg Dynamic/Observed LAP Left Atrial Pressure mm HgDynamic/Observed RAP Right Atrial Pressure mm Hg Dynamic/Observed ΔPPulse Pressure mm Hg Derived/Observed CO Total Cardiac Output L/min/m²Derived Q_(p) Pulmonary rate of blood flow L/min/m² Derived Q_(s)Systemic rate of blood flow L/min/m² Derived Q_(p):Q_(s) Ratio of Q_(p)to Q_(s) Derived ΔQ_(P):Q_(S) Change in Ratio of Qp to Qs per time stepDerived c_(DO2) Oxygen Delivery feedback constant — c_(VO2) OxygenConsumption feedback constant — c_(Hb) Hemoglobin feedback constant — c₃Aortic compliance scaling constant — c₄ Aortic compliance offset — c₅Hemoglobin oxygen carrying capacity —

Table 1 lists state variables that may be used in the model of HLHSphysiology after stage 1 palliation, the variable description, units,and type of variable. A person reasonably skilled in the relevant artswill recognize that though these variables encompass circulation,hemodynamic, and the oxygen exchange components of HLHS physiology, themodels can be altered or enhanced with any additional physiologiccomponents such as ventilation, metabolism, etc. without altering thepremise of the disclosed invention.

FIG. 32 depicts a general Dynamic Bayesian Network (DBN) that may beemployed to capture the physiology model of the HLHS stage 1 palliationpatients. The graphical model illustrated conceptually in FIG. 32captures the causal and probabilistic relationship between the variablesof the model. In the DBN, the state variables are organized into threegroups: dynamic variables 3210, derived variables 3220, and observedvariables 3230. Dynamic variables 3210 are variables whose values changeover time based on a dynamic probabilistic model to be described below.Derived variables 3230 are quantities that depend on the dynamicvariables with some functional relationship. These variables arecomputed or derived when required from the latest dynamic variables andare therefore also dynamic in nature. Observed variables 3230 are thosevariables that are measured directly by one of the sensors connected tothe system and the patient. Observed variables 3230 represent instancesof the true dynamic or derived states variables that have been observedunder noise.

FIG. 33 lists several equations that may be used to model the dynamicsof the HLHS stage 1 physiology. The model consists of four main types ofstochastic models. The first type of model is a stochastic feedbackcontrol model (eqs. 1, 2, and 7). These variables have a nominal valuethat the body maintains, but are disturbed by some random process off ofthis nominal value. The strength at which the body attempts to maintainthese values is decided by the feedback constant. The second type ofmodel is a drift diffusion process (eqs, 3 and 4). These variables aredriven over time by a random white noise process and a drift rateprocess. The third type of model is a simple random walk process (eqs.5, 6, and 8). The last type of dynamic model is a memory-less processmodel in which the variable has no relationship to the variable at theprevious time period, but is simply a random variable which valuechanges at each time instance according to some predefined distributionover the proper support of the variable, i.e. a gamma distribution overthe entire positive real line with parameters A and B. (eqs. 9, 10, and11). With the exception of equations 9, 10, and 11, the driving noisefor each dynamic model is independent white Gaussian noise.

FIG. 34 depicts example equations that may be used to abstract therelationships between the dynamic variables in the model and the derivedvariables. Some of these functional relationships are true for generalhuman physiology, but many are the result of the parallel circulationphysiology that is specific to the HLHS population. Equations 12-15describe relationships for variables that are measured directly.Equations 16-18 describe functional relationships for variables that areof highest interest when managing care of HLHS patients post-surgery,specifically Cardiac Output (CO) and Pulmonary to Systemic Flow ratio(Qp:Qs). These variables cannot be measured directly without complexprocedures.

Given these functional relationships and the definition of the dynamicstates, FIG. 35 now provides a possible observation model that may beused to relate the derived variables with the available sensor data.Each observation model is a conditional Gaussian relationship. Underthis model, the measurement received from the sensor represents a directobservation of the underlying state variable corrupted by additionalindependent Gaussian White noise with some variance. The figure depictsthe observed quantity as the underlying state variable with a tilde overthe variable name. In this implementation, different sensors can map tothe same underlying state variable, but with potentially different noiselevels. For example, SpO2 as reported by a pulse oximeter measures theunderlying physiology state, SaO2 or arterial oxygen saturationnon-invasively. An intravenous catheter inserted directly into thearterial blood stream also measures this quantity but in an invasiveway. The catheter measurement should be a more accurate measurement thanthe pulse oximetry. In this model, this is handled with a smallermeasurement variance, R.

In the HLHS physiology observer, inference over the DBN is performedusing a particle filter. As described earlier, a particle filter is anexample of an approximate inference scheme that uses Monte Carlo samplesof the internal state variables to approximate the probability densityfunction of each state variables with an empirical distribution based onthe number of particles. The filter uses a process known as SequentialImportance Sampling (SIS) to continuously resample particles from themost recent approximate probability distribution. In the filter, eachparticle is assigned a weight. When a new observation or measurementarrives, the weights of each particle are updated based on thelikelihood of the particular particle given the observation. Theparticles are then resampled based on their relative updated weights,the particles with the highest weights being more likely to be resampledthan those with lower weights.

FIG. 36 illustrates possible attributes, patient states, and an etiologytree that may be used by the clinical trajectory interpreter module 123in the case of the HLHS Stage 1 population. The variable total cardiacoutput defined as the sum of the systemic and the pulmonary blood flowsis used to define low and normal total cardiac output, the Qp:Qs ratiois used to derive low, balanced, and high Qp:Qs ratio, the value ofhemoglobin concentration Hgb is used to derive low and normalhemoglobin, and the value of the mixed venous oxygen saturation, SvO2,is used to derive the attributes hemodynamic shock and no hemodynamicshock. This results in eight possible states defined as follows: 1)Shock caused by low total cardiac output, as the presence of both of theattributes Shock and low total cardiac output; 2) Shock caused by lowhemoglobin as the state with attributes shock, normal total cardiacoutput, and low hemoglobin; 3) shock from unknown causes as the statewith the attributes shock, normal total cardiac output, normalhemoglobin, and balanced circulation; 4) shock cause by low Qp:Qs as thestate with the attributes shock, normal total cardiac output, normalhemoglobin, and low Qp:Qs; 5) shock cause by high Qp:Qs as the statewith the attributes shock, normal total cardiac output, normalhemoglobin, and high Qp:Qs; 6) normal circulation as a state with theattributes of no shock and normal circulation; 7) low Qp:Qs as the statedefined by the attributes of no shock and low Qp:Qs; and 8) high Qp:Qsas the state defined by the attributes of no shock and high Qp:Qs. FIG.35 also illustrates a possible realization of an etiology treedescribing the relationships between the attributes and the patientstates. Using the particles approximation of internal state variablesthe probability of the eight states can be calculated by calculating therelative fraction of particles within each state.

Example of Applying the Risk-Based Monitoring System in Conjunction withEvaluating Consequences of a Possible Treatment

Another possible application of the risk based monitoring system is toassist clinicians when deciding whether to apply a particular treatment,one example being blood transfusion. Transfusion of blood and bloodproducts is a common in-hospital procedure. Despite that bloodtransfusion indications and policies are neither well established norconsistently applied within or between medical centers. Multiple studieshave demonstrated variation in transfusion practices among differenthospitals, practitioners, and procedures. This variation persists evenwhen applied to a single procedure (e.g. coronary artery bypass graftsurgery).

Moreover, blood transfusion has been increasingly recognized as anindependent risk factor for morbidity and mortality. Specific events andoutcomes associated with transfusion include sepsis, organ ischemia,increased time on ventilation support, increased hospital length ofstay, and short- and long-term morbidity. This relationship isproportional to the transfusion volume, and evidence suggests that highhematocrit values may be detrimental. Understandably, researchersconventionally recommend transfusion policies aimed at achieving aninformed tradeoff between the risks and benefits.

Setting robust and effective transfusion policies has been proven to bea difficult task. The consensus in the medical community is that simplepolicies—such as hemoglobin threshold policies—do not provide adequateguidance. This is due to the compensatory nature of hemodynamicphysiology; patients have a variable capacity to tolerate lowhemoglobin. Consequently, effective transfusion decision-making mustintegrate factors such as compensatory reserve, intravascular volume,hemodynamic stability, procedure type, and other patient data. Thus,there is an essential need for blood management policies that willutilize the full spectrum of relevant clinical variables and determinethe risk/benefit ratio of transfusion. This is exactly afforded byapplying the risk based monitoring system.

FIG. 37 illustrates one possible environment in which the risk basedmonitoring system can be applied to assist clinicians in decidingwhether to apply a particular treatment. Consistent with the disclosure,a patient 101 is being monitored with multiple measurements 3910, bothintermittently and persistently. The persistent measurements may includemixed venous oxygen saturation (SvO2) 3911, systolic, diastolic and meanarterial blood pressures (ABP s|d|m) 3913, heart rate 3916, monitoredvia a bedside monitor. The intermittent measurements may include bloodpH 3915, hemoglobin concentration (Hgb) 3912, and lactic acidconcentration 3914 monitored through periodic blood works. Thesemeasurements 3910 are fed into an enhanced risk based monitoring system3940 with treatment evaluation, which, in addition to the previouslydisclosed physiology observer module 122 and clinical trajectoryinterpreter module 123, consists of several other modules. A possibletreatment complications determination module 3924 receives informationfrom the clinical trajectory interpreter module 123, together withinformation about the patient demographics 3931 and type of procedure3932. With the information, this module 3924 queries an outcome database3943 and receives back information of what the probability of differentcomplications can be given that a) the patient is in particular patientstates with particular probabilities; b) the patient is of certaindemographics (age, sex, etc); c) the patient has had a particular typeof procedure; d) and any combinations thereof of a) b) and c). On theother hand, the outcome database 3943 can be populated by using outcomestudies 3990 derived from retrospective studies 3991, randomizedclinical trials 3992, institution specific outcomes 3993 determined frompreviously collected patient data for a particular institution, and anycombination thereof of the proceeding elements.

When the possible treatment complications determination module 3942determines the possible complications, it feeds this information back toan enhanced visualization and user interactions module 3941. Theenhanced visualization and user interactions module 3941 combines thepatient-specific risk based monitoring performed by the physiologyobserver module 122 and the clinical trajectory interpreter module 122,with the evaluation of probable complication. This affords the system toprovide a superior vantage point from which the clinician 3920 canbetter recognize risks and benefits of treatments such as bloodtransfusion, and respectively more efficiently and effectively decidewhether to administer this treatment 3960 or not.

FIG. 38 shows a non-limiting example set of patient states relevant toblood transfusion that may be used to inform the blood transfusiondecision. The states contain information about the dynamics of thehemoglobin (decreasing/stable/increasing) and the hemodynamiccompensation for reduced blood oxygen carrying capacity. Inuncompensated patients, the hemodynamic auto-regulation mechanismsbecome incapable of overcoming the depleted blood oxygen carryingcapacity, marking the onset of anaerobic metabolism. These seven statescan be determined through three internal state variables: oxygendelivery, hemoglobin, and rate of hemoglobin production/loss.Specifically, when hemoglobin is above 13 mg/dL, it is assumed thatthere is no Hgb related pathology 4001. When Hgb is lower than 13 mg/dL,there are six other states, determined through five differentattributes. From the oxygen delivery ISV, the system can determinewhether the patient is compensated or uncompensated, e.g., it may beassumed that DO2 above 400 ml/min/m², for ventilated and paralyzedpatient, indicates compensation, and below this value uncompensatedpatient. The other three attributes are determined from the Hgb rate ISVand are stable 4013 and 4014 (the rate is close to zero), increasing4011 and 4012 (the rate is positive), and decreasing 4015 and 4016 (therate is negative).

Using the Risk Based Monitoring System with Standardized Clinical Plan

Yet another application of the risk based monitoring system is inapplying standardized medical plans. FIG. 39 illustrates one possibleembodiment of this application. Specifically, the data from the clinicaltrajectory interpreter module 123 is fed to a treatment query module4142. The treatment query module 4142 queries a treatment plan database4143 based on the determined patient risks. The treatment plan database4143 specifies a map between patient risks and treatments. When thedatabase 4143 returns a treatment plan, it is represented to theclinician 3920 by an enhanced visualization and user interactions module4141 with plan. The clinician 3920 can then make clinical decision 4190with respect to patient 101. The user decision, the context under whichit was taken, (the calculated patient risks, the estimated ISVs, andother possible patient data at the time of the decision) are thenrecorded to a decision data base 4144. The decision database 4144 thencan be compared to patient outcomes and utilized in the improvement ofthe treatment plan.

FIG. 40 illustrates an example application of the risk based monitoringsystem 4240 combined with a specific type of standardized clinical plan.The particular example considers the medical decision whether to treatthe patient with nitric oxide. Nitric oxide is a pulmonary vasodilatorand is used to treat high pulmonary vascular resistance and ensuingpulmonary hypertension, which can cause reduced cardiac output. In theexample, the medical plan uses the risks calculated by the clinicaltrajectory interpreter module 123 and stratifies 4230 them into twocategories: low risk and high risk. If the risks are low 4201 therecommended decision is not to treat 4202, respectively, if the patientis classified as being in high risk the recommended decision is to treat4203. The provider can then make a decision to either follow therecommendations 4250 or disregard them 4260. If the provider chooses todisregard the treatment recommendation for a high risk patient, he needsto provide justification 4220. Likewise, if the provider chooses totreat a low risk patient, he also needs to provide justification 4210.Justifications 4210 and 4220 in conjunction with patient outcomes may beutilized to refine the risk stratification 4230 and risk-basedmonitoring system 100.

FIG. 41 illustrates the example risk stratification that may be employedby the system in the context of Nitric Oxide treatment. Specifically, itassumes that the patient can be in four different states: State 1: LowCO, Normal PVR; State 2: Low CO, High PVR; State 3: Normal CO, High PVR;State 4: Normal CO Normal PVR. A patient being in low risk may bedefined as P(State 1)<10% and P(State 1)+P(State 2)<30%. Similarly highrisk may be defined as: P(State 1)>10% and P(State 1)+P(State 2)>30%.

Using the Clinical Risk Assessment System in Outpatient Care of ChronicConditions

Yet another embodiment of the present disclosure allows the clinicaltrajectory tracking in outpatient care. Outpatient care of chronicconditions involves sporadic patient assessment from intermittentvisits, patient self-evaluations, and observations from caregivers. Thisleads to uncertainties in determining the patient clinical course andthe efficiency of the prescribed treatment strategy. To achieveeffective patient care management, clinicians must understand and reducethese uncertainties. They have two main decisions at their disposal: 1)schedule visits, prescribe tests, or solicit self-evaluation (orcaregiver evaluations) to improve their understanding of the clinicaltrajectory; and/or 2) prescribe changes of medication or medicationdosing to achieve a better trade-off between the likelihood ofimprovement and possible side-effects. To inform this decision makingprocess, there is a need for processing the available patientinformation in a way that conveys the clinical trajectory, theuncertainty in its estimation, and the expected effect that differenttreatment strategies may have on the future evolution of the clinicaltrajectory.

As a non-limiting example embodiment of the risk based monitoring systemto outpatient clinical trajectory tracking, we consider its applicationto the outpatient care of Attention Deficit and Hyperactivity Disorder(ADHD) of pediatric patients. FIG. 42 illustrates possible patientstates that may describe the clinical trajectory of an ADHD patient.They are the same as the ones used by the Clinical globalimpression-improvement scale: 1) very much worse; 2) much worse; 3)worse; 4) No change; 5) Minimally Improved; 6) Much improved; 7) Verymuch improved. The Patient State Distribution (PSD) is the set ofprobabilities that the patient is in any of the seven states, given allavailable information and observations.

To evaluate the patient state, a clinician may either schedule an officevisit for direct examination, or may request a Vanderbilt diagnostictest from family members or teachers (the test is modified depending onthe respondent, teacher or parent). FIG. 43 lists the available patientevaluation modalities as M1. M2 and M3. Models may be used to map thetest questions and answers into the states of the patient. Both theclinical evaluation and the test-based evaluation are associated withuncertainty that prohibits the exact determination in which of the sevenstates the patient currently resides.

The dynamic model or the patient evolution from state to state may beabstracted by a Dynamic Bayesian Network (DBN) as the one shown in FIG.44. In FIG. 44, the arcs' directions signify statistical dependence,i.e., the connection from “Patient state @ t1” 4601 to “M1”, signifiesthe probability density function (PDF): P(M1|Patient state @ t1).Similarly, the depicted DBN illustrates that “Patient state @ t2” 4602(the patient state at a particular time t2), is conditioned on the“Patient state @ t1” (the patient state at the previous time incrementt1). In the spirit of the present disclosure, this model enables theestimation of the patient state distribution even in the absence of someor all possible measurements, e.g., as illustrated in the figure at timeinstance t2 when M1 is missing, and at time instance t3 (“Patient state@ t3” 4603), when all measurements are missing.

FIG. 45 illustrates an alternative embodiment for two predictions of howthe patient state can transition in a single month given medicationchange or a dosage change. This prediction is performed based on astatistical model derived in the following fashion: Step 1: Isolate agroup of patients from retrospective data which at some point of theirtreatment have passed through State A and received a change of treatment(Med1 Dose1->Med 2 Dose 2); Step 2: For each patient, set the timeinstance that this particular event occurred to t0; 3) step 3: for eachpatient identify what is the patient state at time t0+1 Month (1M) (orany desired time step unit). 4) calculate the fraction of patients thattransition State A->State i where i stands for all seven possiblepatient states; 5) set the fraction as the probabilities for transitionunder the particular treatment change.

FIG. 46 shows one possible embodiment and scenario of visualizationdisplaying the patient clinical trajectory and risks. The user interfacedenotes that the patient is at “no change” state, and that this has beenestablished by three separate measurements: office visit, teacher basedVanderbilt diagnosis, and parent based Vanderbilt diagnosis. The solidline on the screen signifies that a medication has been prescribed tothe patient (Medication 1) at week 1 of the treatment.

FIG. 47 shows an evaluation of the patient and the patient trajectory atweek 9 at which point the clinical risk assessment system determines aprobability density function for the state of the patient for each ofthe past six weeks. The available measurements at this point are teacherand parent Vanderbilt diagnosis. In the illustrated example, due to ahigh probability of a deteriorating patient state, the clinicianprescribes a change of medication dosing, which is depicted by a dashedred line. Additionally, the user interface shows the side effectreported by the patient—headache.

FIG. 48 shows a follow-up evaluation based on teacher and parentVanderbilt diagnosis. In the example, the clinician decides a medicationchange depicted by a hollow line.

FIG. 49 shows consequent evaluation based on all availablemeasurements—office visit, parent and teacher evaluation, whichestablishes high probability for significant improvement.

FIG. 50 shows yet another follow-up at which point it is establishedthat the patient is most probably stably improved, and has been stablyimproved between the two evaluations. Note that due to the appliedinference, the PDF for the patient trajectory is continuously estimated.However, the precision (the concentration of the PDF) is higher in thepresence of a measurement.

FIG. 51 shows a follow-up evaluation of the patient and the patienttrajectory in the absence of measurements. Due to the lack of recentobservations, the uncertainty is increasing.

FIG. 52 shows the state of this uncertainty given a full patientevaluation (all measurement modalities). The inference engine propagatesthis uncertainty back in time to produce a more precise estimation ofthe patient trajectory, which helps the clinician to deduct that thepatient is stable.

FIG. 53 illustrates yet another possible visualization from thedescribed system output. It shows possible patient state transitionsunder changes of treatment plan, e.g., change of medication. It alsoconveys what possible side-effects can be expected. For every sideeffect, there are three stages of manifestation—mild, moderate, andsevere represented with the three boxes next to each side effect in thefigure. The coloring corresponds to the probability of a particularseverity manifestation for each particular side-effect, with darkercolors indicating higher probability.

Various examples and embodiments consistent with the present disclosurehave be described in detailed above. It is to be understood that theseexamples and embodiments of the present disclosure are provided forexemplary and illustrative purposes only. Various modifications andchanges may be made to the disclosed embodiments by persons skilled inthe art without departing from the scope of the present disclosure asdefined in the appended claims.

What is claimed is:
 1. A method of determining a hidden internal statevariable of a patient, which hidden internal state variable cannot bedirectly measured, the method comprising: acquiring, by a computer,measurements of internal state variables over a sequence of time stepst_(k−3), t_(k−2), t_(k−1), at least some of the measurements(“continuous measurements”) measured at each time step of the sequenceof time steps, and at least one of the measurements (“intermittentmeasurements”) measured at only a subset of the time steps, the subsetof time steps including fewer than all time steps of the sequence oftimes steps; for each time step t_(n) of the sequence of time steps:generating a conditional likelihood kernel for said time step t_(n),said conditional likelihood kernel comprising conditional probabilitydensity functions of the measurements acquired at said time step t_(n);generating, by the computer, using at least the continuous measurements,and for at least one time step of the sequence of time steps also usingthe intermittent measurements, predicted probability density functionsof internal state variables for the time step t_(n), wherein thepredicted probability density functions are calculated using posteriorestimated probability density functions for each of the internal statevariables from a preceding time step t_(n−1); and generating, with thecomputer and using Bayes theorem operating on the conditional likelihoodkernel and predicted probability density functions of internal statevariables for the time step t_(n), posterior predicted probabilitydensity functions for each of the plurality of the internal statevariables for the time step t_(n); determining, based on the generatedposterior predicted probability density functions for the plurality ofthe internal state variables for the time step t_(n), a value of thehidden internal state variable; and substantially continuouslydisplaying, on a graphical user interface, the value of a hiddeninternal state variable.
 2. The method of claim 1, wherein measurementsfor a first internal state variable are intermittent measurements and,at a time step t_(n) of the first sequence of time steps, said firstinternal state variable is not measured, and wherein generating theconditional likelihood kernel for said time step t_(n) comprises:generating a conditional probability density function of said firstinternal state variable for time step t_(n) (i) using a predictedprobability density function of said first internal state variable forthe time step t_(n), which predicted probability density function ofsaid first internal state variable was generated at a preceding timestep t_(n−1), but (ii) without using a measurement acquired for saidfirst internal state variable at said time step t_(n); and generatingconditional probability density functions of a second internal statevariable for time step t_(n) using: (a) measurements acquired for saidsecond internal state variable at said time step t_(n) and (b) predictedprobability density functions of said second internal state variable forthe time step t_(n), which predicted probability density functions ofsaid second internal state variable were generated at a preceding timestep t_(n−1).
 3. The method of claim 1, further comprising:substantially continuously estimating a clinical trajectory for thepatient at each time step of the sequence of time steps, the patient'sclinical trajectory being described by probabilities of possible patientstates using data acquired at a subsequent time step from at least aheart rate sensor and an SpO2 sensor attached to the patient, andposterior predicted probability density functions from a previous timestep.
 4. The method of claim 1, further comprising: providing aplurality of sensors, each sensor of the plurality of sensors beingconfigured to be physically attachable with the critical care patient;and attaching the plurality of sensors to the patient.
 5. The method ofclaim 4, wherein the plurality of sensors comprise a heart rate sensorand an SpO2 sensor.
 6. A system configured to determine a hiddeninternal state variable of a patient, which hidden internal statevariable cannot be directly measured, the system comprising: a datareception module configured to receive, from sensors coupled to thepatient, measurements of internal state variables over a sequence oftime steps t_(k−3), t_(k−2), t_(k−1), at least some of the measurements(“continuous measurements”) measured at each time step of the sequenceof time steps, and at least one of the measurements (“intermittentmeasurements”) measured at only a subset of the time steps, the subsetof time steps including fewer than all time steps of the sequence oftimes steps; an observation module configured, for each time step t_(n)of the sequence of time steps, to generate a conditional likelihoodkernel for said time step t_(n), said conditional likelihood kernelcomprising conditional probability density functions of the measurementsacquired at said time step t_(n); a predict module configured togenerate, using at least the continuous measurements, and for at leastone time step of the sequence of time steps also using the intermittentmeasurements, predicted probability density functions of internal statevariables for the time step t_(n), wherein the predicted probabilitydensity functions are calculated using posterior estimated probabilitydensity functions for each of the internal state variables from apreceding time step t_(n−1); an inference engine configured to generate,using Bayes theorem operating on the conditional likelihood kernel andpredicted probability density functions of internal state variables forthe time step t_(n), posterior predicted probability density functionsfor each of the plurality of the internal state variables for the timestep t_(n); a clinical trajectory interpreter module configured todetermine, based on the generated posterior predicted probabilitydensity functions for the plurality of the internal state variables forthe time step t_(n), a value of the hidden internal state variable; anda display module configured to display, on a graphical user interface,the value of a hidden internal state variable.
 7. The system of claim 6wherein measurements for a first internal state variable areintermittent measurements and, at a time step t_(n) of the firstsequence of time steps, said first internal state variable is notmeasured, and wherein the observation module is configured: to generatea conditional probability density function of said first internal statevariable for time step t_(n) (i) using a predicted probability densityfunction of said first internal state variable for the time step t_(n),which predicted probability density function of said first internalstate variable was generated at a preceding time step t_(n−1), but (ii)without using a measurement acquired for said first internal statevariable at said time step t_(n); and to generate conditionalprobability density functions of a second internal state variable fortime step t_(n) using: (a) measurements acquired for said secondinternal state variable at said time step t_(n) and (b) predictedprobability density functions of said second internal state variable forthe time step t_(n), which predicted probability density functions ofsaid second internal state variable were generated at a preceding timestep t_(n−1).
 8. The system of claim 6, wherein said system is furtherconfigured to substantially continuously estimate a clinical trajectoryfor the patient at each time step of the sequence of time steps, thepatient's clinical trajectory being described by probabilities ofpossible patient states using data acquired at a subsequent time stepfrom at least a heart rate sensor and an SpO2 sensor attached to thepatient, and posterior predicted probability density functions from aprevious time step.
 9. The system of claim 6 further comprising thesensors coupled to the patient.
 10. The system of claim 9, wherein thesensors coupled to the patient include at least heart rate sensor and anSpO2 sensor.
 11. A computer program product comprising non-transientcomputer executable instructions, which computer executableinstructions, when executed by a computer, cause the computer toimplement a process comprising: acquiring, by a computer, measurementsof internal state variables over a sequence of time steps t_(k−3),t_(k−2), t_(k−1), at least some of the measurements (“continuousmeasurements”) measured at each time step of the sequence of time steps,and at least one of the measurements (“intermittent measurements”)measured at only a subset of the time steps, the subset of time stepsincluding fewer than all time steps of the sequence of times steps; foreach time step t_(n) of the sequence of time steps: generating aconditional likelihood kernel for said time step t_(n), said conditionallikelihood kernel comprising conditional probability density functionsof the measurements acquired at said time step t_(n); generating, by thecomputer, using at least the continuous measurements, and for at leastone time step of the sequence of time steps also using the intermittentmeasurements, predicted probability density functions of internal statevariables for the time step t_(n), wherein the predicted probabilitydensity functions are calculated using posterior estimated probabilitydensity functions for each of the internal state variables from apreceding time step t_(n−1); and generating, with the computer and usingBayes theorem operating on the conditional likelihood kernel andpredicted probability density functions of internal state variables forthe time step t_(n), posterior predicted probability density functionsfor each of the plurality of the internal state variables for the timestep t_(n); determining, based on the generated posterior predictedprobability density functions for the plurality of the internal statevariables for the time step t_(n), a value of the hidden internal statevariable; and substantially continuously displaying, on a graphical userinterface, the value of a hidden internal state variable.
 12. Thecomputer program product of claim 11, wherein measurements for a firstinternal state variable are intermittent measurements and, at a timestep t_(n) of the first sequence of time steps, said first internalstate variable is not measured, and wherein generating the conditionallikelihood kernel for said time step t_(n) comprises: generating aconditional probability density function of said first internal statevariable for time step t_(n) (i) using a predicted probability densityfunction of said first internal state variable for the time step t_(n),which predicted probability density function of said first internalstate variable was generated at a preceding time step t_(n−1), but (ii)without using a measurement acquired for said first internal statevariable at said time step t_(n); and generating conditional probabilitydensity functions of a second internal state variable for time stept_(n) using: (a) measurements acquired for said second internal statevariable at said time step t_(n) and (b) predicted probability densityfunctions of said second internal state variable for the time stept_(n), which predicted probability density functions of said secondinternal state variable were generated at a preceding time step t_(n−1).13. The computer program product of claim 11, wherein said processfurther comprises: further comprising: substantially continuouslyestimating a clinical trajectory for the patient at each time step ofthe sequence of time steps, the patient's clinical trajectory beingdescribed by probabilities of possible patient states using dataacquired at a subsequent time step from at least a heart rate sensor andan SpO2 sensor attached to the patient, and posterior predictedprobability density functions from a previous time step.
 14. A method ofdetermining a hidden internal state variable of a patient, which hiddeninternal state variable cannot be directly measured, the methodcomprising: acquiring, by a computer at time step t_(k+1), physiologicaldata from a plurality of sensors connected to the patient, the pluralityof sensors comprising a heart rate sensor and the SpO2 sensor;generating, by the computer, predicted probability density functions ofinternal state variables for the time step t_(k+1), wherein thepredicted probability density functions are calculated using posteriorestimated probability density functions for each of the internal statevariables from a preceding time step t_(k); computing a conditionallikelihood kernel, said conditional likelihood kernel comprisingconditional probability density functions of the physiological dataacquired at a time step t_(k+1); generating, with the computer and usingBayes theorem with the conditional likelihood kernel and the predictedprobability density functions of internal state variables for the timestep t_(k+1), posterior predicted probability density functions for theplurality of the internal state variables for the time step t_(k+1);determining, based on the generated posterior predicted probabilitydensity functions for the plurality of the internal state variables forthe time step t_(k+1), a value of the hidden internal state variable;and substantially continuously displaying, on a graphical userinterface, the value of a hidden internal state variable.
 15. The methodof claim 14 further comprising: substantially continuously estimating aclinical trajectory for the patient at each time step of the sequence oftime steps, the patient's clinical trajectory being described byprobabilities of possible patient states using data acquired at asubsequent time step from at least a heart rate sensor and an SpO2sensor attached to the patient, and posterior predicted probabilitydensity functions from a previous time step.
 16. The method of claim 14further comprising: providing a plurality of sensors, each sensor of theplurality of sensors being configured to be physically attachable withthe critical care patient; and attaching the plurality of sensors to thepatient.
 17. The method of claim 16, wherein the plurality of sensorscomprise a heart rate sensor and an SpO2 sensor.
 18. The method of claim14 wherein generating predicted probability density functions for theplurality of the internal state variables comprises: comparing a newlyreceived measurement associated with the internal state variable with apredetermined predicted likelihood of probable measurements givenpreviously received measurements; and not incorporating the newlyreceived measurement into the predicted probability density function forthe associated internal state variable, if the newly receivedmeasurement is not within the predetermined predicted likelihood ofprobable measurements for the associated internal state variable. 19.The method of claim 14 wherein generating predicted probability densityfunctions of internal state variables for the time step t_(k+1),comprises: generating predicted probability density functions for afirst plurality of the internal state variables at a time step t_(k);receiving, from a source, external computational data associated with aparticular one of the plurality of the internal state variables; andgenerating probability density functions for the plurality of theinternal state variables at time step t_(k+1) from: the probabilitydensity functions generated at a time step t_(k) and from: receivedmeasurements associated with respective ones of the internal statevariables; and the external computational data associated with theparticular one of the plurality of the internal state variables.
 20. Themethod of claim 14 wherein the predicted probability density functionsare calculated using posterior predicted probability density functionsfor each of the internal state variables from the preceding time stept_(k), using the formula:P(ISVs(t _(k+1))|M(t _(k)))=∫_(ISVsϵISV) P(ISVs(t _(k+1))|ISVs(t_(k)))P(ISVs(t _(k))|M(t _(k)))dISVs.